ICD-10 Compliance

FAQ

FAQs

Why ICD-10?ICD-10-CM (Diagnosis Codes) replaced ICD-9-CM volumes 1 & 2, and ICD-10-PCS (Inpatient Procedure Codes) replaced ICD-9-CM volume 3. The transition to ICD-10 occurred because ICD-9 procedures limited data about patients' medical conditions and hospital inpatient procedures. ICD-9 was 30 years old, had outdated terms, and was inconsistent with current medical practice. Also, the structure of ICD-9 limited the number of new codes that can be created, and many ICD-9 categories were full.

Does WellCare still accept ICD-9 codes?WellCare's systems will align with guidelines from CMS and support the following: Claims for all services and hospital inpatient procedures performed on or after the compliance deadline must use ICD-10 diagnosis and inpatient procedure codes. (This does not apply to CPT coding for outpatient procedures.) Claims that do not use ICD-10 diagnosis and inpatient procedure codes cannot be processed. Claims for services and inpatient procedures provided before the compliance date must use ICD-9 codes.

Can WellCare adjudicate diagnosis-dependent claims?WellCare's configuration strategy supports dual processing of ICD-9 and ICD-10 claims based upon date of service and CMS Guidelines. Claim submission must designate a transaction as ICD-9 or ICD-10 using the qualifier field. Only one code set (either ICD-9 or ICD-10) is acceptable per claim. WellCare's policy is to use a "qualifier" approach to transition our information systems to the ICD-10 standard. WellCare does not, however, support a single claim containing a combination of ICD-9 and ICD-10 codes.

How does WellCare handle authorization of services that occurred on or after the ICD-10 compliance date?

We will follow WellCare's current process, which is to issue authorizations based on request date.

If an authorization was requested on or before the compliance date, and the date of service was on or after October 1, 2015, providers should submit an ICD-10 code.

If the authorization is requested after the compliance date, the ICD-10 code will be required.

For existing approved prior authorizations coded in ICD-9 whose effective period spans the ICD-10 implementation date of October 1, 2015, there is no need to obtain another authorization.

WellCare is currently accepting ICD-10 codes for authorizations and referrals whose start of care is October 1, 2015 or later.

Does WellCare use the Center for Medicare & Medicaid Services (CMS) ICD-10 General Equivalency Maps (GEMs) crosswalks?General Equivalency Maps (GEMs) were used along with WellCare custom clinical and coding mappings to address gaps in GEMs during the transition.

Did WellCare's pre-authorization policy and/or guidelines for requesting pre-authorizations change with the implementation of ICD-10?All claims are dependent upon a valid diagnosis code being submitted. WellCare has the ability to auto-adjudicate ICD-10 claims in the same manner we auto-adjudicated ICD-9 claims.

What percent of claims processed and paid claims are based on ICD codes?All claims processed and paid are based upon procedure code fee schedules or Optum Pricers. Dollar amount is driven by either the CPT, HCPC, Rev Code or DRG assigned to the claim.